RAY SUAREZ: The numbers are sobering. The federal government estimates that each year about 100,000 people die in the U.S. after acquiring one or more infections during their stays at a hospital.

In fact, one new study, the first to quantify the number of these infections in Pennsylvania, found that patients with hospital-acquired infections were nearly six times as likely to die as other hospital patients who did not contract them.

Today, researchers published new findings about the causes and costs of this problem in a special issue of the American Journal of Medical Quality. Dr. Richard Shannon, of the University of Pennsylvania’s Department of Medicine, is one of the authors, and he joins me now.

We mentioned six times more likely to die, but, Doctor, in the Pennsylvania hospitals you studied, is this a widespread, common occurrence?

DR. RICHARD SHANNON, University of Pennsylvania: Well, I think, Ray, it’s very clear from the report in Pennsylvania that these infections occur far more commonly than we ever thought. And I think my own experience in my own hospital is that very recently we’ve recognized that these can be everyday occurrences. So, clearly, the problem is substantial.

RAY SUAREZ: How do you distinguish between something that was actually caught during a hospital stay and the illnesses that a patient already had when they came through the door?

DR. RICHARD SHANNON: Sure, so that in the Pennsylvania health care cost containment report, there were four classes of infections that were the principal focus: infections due to intravenous catheters placed in the vein, called central line infections; surgical site infections, in areas where a surgical wound was created; catheter-related urinary tract infections; and then ventilator-associated pneumonias, pneumonias that occur in people that are on a ventilator.

Now, I think most people only get central catheters and only are on a ventilator in a hospital, so it’s pretty easy to understand those two classes of infections. Similarly, most surgical procedures occur in the hospital, and so someone that develops a fever in a post-operative period and has an infection in their wound is pretty easy to recognize.

I think the one area where it is somewhat controversial are the urinary-tract infections, because people at home and as outpatients can sometimes have bacteria in their bladder and be asymptomatic, and so that could well be present when they’re admitted. But the overwhelming majority of the infections reported here clearly occurred while the patient was in the hospital.

Prevalence of hospital infections

RAY SUAREZ: The overwhelming majority. Now, is this bad practice or is this just the risk of getting treatment for these kinds of illnesses in a hospital?

DR. RICHARD SHANNON: Well, I think that it's been long considered that these are an inevitable consequence of the complex care in the very sick patients that come to the hospital today. But our own experience in Pittsburgh, at Allegheny General Hospital, suggested that, while sicker patients are at greater risk, that the principal cause in most of these infections are variations in processes and that the delivery of care has not been reliable in many regards.

For example, we observed in our own work that doctors had six or seven different ways in which they gowned and scrubbed to perform a central line procedure. There were different ways in which nurses and respiratory therapists cared for endotracheal tubes.

When we were able to specify and standardize the way in which those processes were conducted, we were able to eliminate a lot of the variation that we believe is the breeding ground for these errors. So a lot of these infections are truly preventable by simply standardizing the delivery of care, yet some of them clearly are going to persist as a result of the critical illness that many patients have.

RAY SUAREZ: Were the hospitals that you looked at willing to be overseen in this way, to have their processes, the way they take care of patients, watched in order to catch these things?

DR. RICHARD SHANNON: Yes, I think it's a good point. You know, the leadership at our hospital, at Allegheny General Hospital in Pittsburgh, and Connie Cibrone, the CEO, had to be very courageous to first allow the observations and then actually to allow the economic analysis to occur.

And so, too, the work that's ongoing now at the University of Pennsylvania, the leadership there has really been very courageous in exposing, opening their doors to outside observers to come in and see these defects.

But we believe that the only way we can overcome them is if we really recognize them. We can't fix it if we don't realize it's broken. And, in fact, inviting in outside observers to help us understand these defects has really been instrumental, but it does take courage. And I think the leaders in my two cases have really been exemplary in that regard.

Identifying the cause

RAY SUAREZ: So what are some of the easy things, some of the low-hanging fruit that hospitals can pick right away?

DR. RICHARD SHANNON: Well, the first thing I think that we need to do that was very successful in our experience in Pittsburgh was, whenever there was an infection, immediately, as soon as we identified it, going to the bedside and trying to figure out, not whodunit, not who was the perpetrator, but rather, what went wrong in the process?

And by interviewing nurses, and nurses aides, speaking to doctors that are involved in the care, you unleash this incredible knowledge and wisdom that these people have about where the defect in the process may have occurred. That allows you to do two things: One is, you can identify that and fix it right away. And, secondly and very importantly, you can say to the patient and their family, "You know, I'm really sorry this infection happened, but we know why, and we're committed to making sure it never happens again."

And I think those two things are going a long way toward really beginning to transform this problem in health care.

RAY SUAREZ: Give me a quick example of a change in hospital procedure that could immediately change patient outcomes in this way?

DR. RICHARD SHANNON: Well, I'll tell you that the most astonishing one to me was the fact that, in a patient that has an endotracheal tube, a breathing tube in their throat that's connected to a ventilator, if you elevate their head of their bed 30 degrees, as opposed to having them lie flat, you can minimize the chance that secretions laden with bacteria in their mouth actually make it into their lung.

So, at no cost, raising the bed 30 degrees in a reliable way every time and making sure everyone that comes in contact with the patient is sufficient to really have a dramatic impact on these ventilator-associated pneumonias, pneumonias that have a mortality that approaches 30 percent and from which the loss on any given case can approach $25,000.

Patients' role in prevention

RAY SUAREZ: And what can patients do? Are they expected to have a role in this improvement, as well?

DR. RICHARD SHANNON: So in the systems that we developed both in Pittsburgh and now at the University of Pennsylvania there are a lot of visual clues. We put, for example, at the head of the bed a sign that says, "If you see red, elevate the head."

So what that means is, if you can see a red line, the patient's head isn't elevated sufficiently. So a patient's family walks in and says, "What's that sign mean?" And a nurse explains to them, "Please, if you ever see the head of the bed not elevated, we want to make sure that you let us know, because we're trying to protect your mom, or your dad, or your friend from contracting these infections."

RAY SUAREZ: And are patients and their families really going to challenge the people who give them care or does that take a sort of cultural change in the way we deal with hospitals and doctors?

DR. RICHARD SHANNON: So we're certainly not there yet, although I think the concept of patient-centered care is beginning to evolve to the point where we're really thinking about families and friends that visit our patients as allies in trying to identify problems that can go wrong. The more eyes you have looking at this, the better.

There's always a concern that a patient's family may not realize the severity or the seriousness of the circumstance and call for help or point out a defect that's unnecessary, but that's not been our experience. Most of the time patients and their families, or families in particular, are deeply interested in trying to make sure that we're doing everything we can to prevent these.

RAY SUAREZ: So if you're not sure, ask. Should this be wet? Should this be changed?

DR. RICHARD SHANNON: Absolutely. Absolutely. Did you wash your hands? I never mind being asked that. In fact, I try and demonstrate to patients when I walk in the room that I, in fact, am washing my hands so that there's no doubt about that. Those are very important clues.

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